Description:

E5103 Registration Worksheet (step 1) Doxorubicin, Cyclophosphamide, and Paclitaxel With or Without Bevacizumab in Treating Patients With Lymph Node-Positive or High-Risk, Lymph Node-Negative Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4C7BBF65-46E3-4B47-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4C7BBF65-46E3-4B47-E044-0003BA3F9857

Keywords:
Versions (3) ▾
  1. 8/26/12
  2. 1/9/15
  3. 9/17/21
Uploaded on:

September 17, 2021

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00433511 Eligibility - E5103 Registration Worksheet (step 1) - 2746547v1.0

No Instruction available.

  1. StudyEvent: E5103 Registration Worksheet (step 1)
    1. No Instruction available.
Eligibility
Has the eligibility checklist been completed
In the opinion of the investigator, is the patient eligible?
Has written informed consent been obtained
Has HIPAA authorization been obtained
Is the tumor ER positive
Lymph Node Involvement
Type of surgery and planned radiotherapy
AC shedule planned
Kg
Do you wish to use an express carrier to ship the drugs (at your expense)?
Name of express carrier
I agree to participate in the laboratory research studies that are being done as part of this clinical trial.
I agree to provide additional blood for research.
I agree to provide urine for research.
My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.
My specimens may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)
Someone from this institution may contact me in the future to ask me to take part in more research.
Patient Demographics / Pre-treatment Characteristics
Patient's Sex
Patient Race (check all that applyU.S. and Canada only)
Patient Ethnicity
Method of payment (check one)

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